Energy level – at what time of day is it……

  • Doc File 67.50KByte



Energy level – at what time of day is it:

□ High ___________

□ Low ___________ | |

| |

| |

|Stress – my current level is…. |

|Low |

|Moderate |

|High |

|Severe |

| |

| |

|Sweating |

|Rarely sweat |

|Excess sweat |

|Night sweats |

| |

|Circulation – I usually…. |

|Feel hot |

|Feel cold |

|Bleed/bruise easily |

|Have cold limbs |

| |

|Skin |

|Dry |

|Itchy |

|Moist / clammy |

|Burning |

|Changing moles or lumps (cysts / tumors) |

|Boils |

|Frequent skin rashes |

|Acne |

|Hair loss / thinning |

|Dry scalp |

|Puffy or wrinkled skin |

|Hives |

|Other _______________________________ |

| |

|Sleep |

|Trouble falling asleep |

|Trouble staying asleep |

|Usually restful |

|Excess or vivid dreaming |

|Average number of hours per night = ________ |

| |

|Head |

|Dizziness |

|Memory loss |

|Loss of balance |

|Light-headedness |

|Headaches |

|Other _______________________________ |

| |

|Eyes |

|Eye pain |

|Dry eyes |

|Blurred vision |

|Double vision |

|Loss of vision |

|Sensitive to light |

|Other _______________________________ |

|Ears |

|Hearing loss |

|Earaches |

|Discharge / infections |

|Ringing / buzzing |

|Other _______________________________ |

| |

|Nose |

|Frequent nose bleeds |

|Sinus trouble |

|Seasonal allergies |

|Frequent colds |

|Other _______________________________ |

| |

|Throat / Mouth |

|Sore throat |

|Hoarseness |

|Difficulty swallowing |

|Jaw problems |

|Tooth / gum problems |

|Swollen tongue |

|Other _______________________________ |

| |

|Chest |

|Difficulty breathing |

|Wheezing |

|Shortness of breath |

|Mucus rattles when breathing |

|Trouble breathing at night |

|Pain / pressure in chest |

|Palpitations |

|Persistent cough |

|Coughing blood |

|Coughing phlegm |

|Other ______________________________ |

| |

|Bowels |

|# of bowel movements per day ____ |

|Diarrhea |

|Constipation |

|Blood in stools |

|Black stools |

|Mucus in stools |

|Hemorrhoids / anal fissures |

|Lower bowel gas |

|Stools have foul odor |

|Other _______________________________ |

| |

|Urine |

|Frequent urination( □ at night □ during the day |

|Strong smelling |

|Difficulty urinating |

|Pain or burning with urination |

|Blood in urine |

|Frequent infections |

|Incontinence |

|Other _______________________________ |

|Musculoskeletal – pain in….. |

|Neck |

|Shoulder |

|Between shoulders |

|Arms / hands – left, right or both |

|Hip |

|Knee – left, right, or both |

|Fingers |

|Big toe |

|Upper back |

|Mid back |

|Lower back |

|Bones sore / painful |

|Loss of grip |

|Swollen knees / elbows |

|Leg cramps at night |

|Weakness in legs |

|Weak ankles |

|Stiff all over |

|Tingling / burning in feet |

|Muscle spasms / cramps |

|Loss of feeling in hands / feet |

|Painful joints |

|Bursitis |

|Other _______________________________ |

| |

|Neurological/Emotional |

|Nervousness |

|Depression |

|Easily angered |

|Easily irritated |

|Frequent crying |

|Worry / anxiety |

|Mood swings |

|Memory confusion |

|Poor concentration |

|Suicidal thoughts / tendencies |

|Tremors |

|Numbness / tingling in limbs |

|Poor coordination |

|Muscle weakness |

|Feel weak and shaky |

|Seizures |

|Neuralgia (nerve pain) |

|Shingles |

|Other ________________________________ |

| |

|Appetite |

|How many meals a day? ____ |

|Specific food cravings ______________________ |

|Excessive appetite |

|Poor appetite |

|Keeps changing |

|Feel tired or weak if a meal is missed |

|Other _______________________________ |

|Thirst |

|How much water do you drink daily? ___ |

|Excessive thirst |

|Never thirsty |

|Other _______________________________ |

| |

|Digestion |

|Stomach gas |

|Lower bowel gas |

|Heartburn/indigestion |

|Burning / belching / acid reflux |

|Stomach pain/cramps |

|Nausea |

|Vomiting |

|Bad breath |

|Sores in mouth |

|Weight gain |

|Weight loss |

|Bitter / sour taste in mouth |

|Abdominal bloating |

|Other _______________________________ |

| |

|Women only: |

|Are you or do you think you are pregnant? Y / N |

|If using birth control, what kind? ____________ |

|Date of last menstrual period ______________ |

|Average length of cycle __________________ |

|Date of last PAP smear __________________ |

|Menstrual pain ( before, during or after period |

|Cramping |

|Irregular cycle / missed periods |

|Heavy bleeding |

|Light / scanty bleeding |

|Clotting |

|Painful breasts |

|Hot flashes |

|Decreased/increased libido |

|Vaginal discharge |

|Fibroids |

|Endometriosis |

|Ovarian cysts |

|Pelvic inflammatory disease |

|Miscarriages |

|Other ________________________________ |

| |

|Men only: |

|Date of last prostate exam _____________ |

|Prostate pain/swelling |

|Decreased/increased libido |

|Impotence |

|Premature ejaculation |

|Testicular pain/swelling |

|Penile discharge |

|Groin pain |

|Urinary abnormalities/changes |

|Other ________________________________ |

................
................

Online Preview   Download